Incarceration-related
Social Network Disruption,
and How HIV Thrives on It
Maria R Khan, PhD, MPH
Department of Epidemiology
College of Public Health and Health
Professions and College of Medicine
University of Florida
Community Disruption and HIV Risk
American University
September 13, 2012
Alarming Association between
Incarceration and HIV
Personal History of Incarceration and HIV
•
Inmates 3-5 times HIV prevalence levels
Sexual Partnership with Former Inmate and HIV
•
North Carolina: Sex partner’s incarceration
associated with 4 times the HIV risk
(SOURCE: Maruschak 2008, Adimora 2006)
2
Many Factors Drive HIV among
those Involved in
Criminal Justice System
Key STI risk factors disproportionately affect individuals
involved in the criminal justice system:
• Poverty (Adimora & Schoenbach 2005, Leichliter et al. 2010)
• Substance use (Fortenberry 1995,Wilson & DeHovitz 1997, Belenko 2005)
• Mental illness (Ramrakha, 2000, Shrier, 2001, Khan et al. 2009, Teplin 1994)
Is criminal justice involvement
also an HIV risk factor?
If it is, why is it? Does the disruptive effect of incarceration
on networks contribute to HIV risk?
3
Overview
• Conceptual Models
• Incarceration as an Independent
HIV Risk Factor
• Individual-, Dyadic-, Network-,
Community-level Studies
• Incarcerated-related Disruption
of Partnerships can Promote HIV
Risk
Conceptual Models
5
Social Context and HIV Risk:
Proximate Determinants Framework
Underlying Determinant
Mobility/Migration
Geographic Factors
Institutional Factors
Racial Factors
Economic Factors
Socio-Cultural Factors
Proximate
Determinants
-Risk of transmission
per contact
-Rate of contact between
susceptible and infected
-Duration of infection
HIV
Typical
Epidemiologic
Variables
SOURCE: Boerma and Weir 2006 Journal of Infectious Diseases
6
The Criminal Justice Involvement and
HIV Risk Model
Underlying
Determinant
Criminal
Justice
Involvement
Intermediate
Determinants
Proximate
Determinants
Disruption of existing
networks
C: Rate of contact
between susceptible
and infected
(Rate of new
partnerships, and
Discordant Partnerships)
Reduction in social
supportAdverse
mental health
outcomes
Outcome
Increased
HIV
Introduction to highrisk networks
Abandonment of
norms
Elevated drug and
alcohol use
SOURCE: Khan, Epperson,
Comfort, APHA 2012
Diminished
employment prospects
and financial solvency
B: Risk of
transmission per
contact
(Use of barrier/chemical
prevention,
access/adherence to
ARVs)
D: Duration of
infectiousness
(Access/adherence to
ARVs)
7
The Criminal Justice Involvement and
HIV Risk Model
Underlying
Determinant
Criminal
Justice
Involvement
Intermediate
Determinants
Proximate
Determinants
Disruption of existing
networks
C: Rate of contact
between susceptible
and infected
Multiple partnerships
Concurrent partnerships
Sex trade
Discordant partnerships
Reduction in social
supportAdverse
mental health
outcomes
Outcome
Increased
HIV
Introduction to highrisk networks
Abandonment of
norms
Elevated drug and
alcohol use
SOURCE: Khan, Epperson,
Comfort, APHA 2012
Diminished
employment prospects
and financial solvency
B: Risk of
transmission per
contact
(Use of barrier/chemical
prevention,
access/adherence to
ARVs)
D: Duration of
infectiousness
(Access/adherence to
ARVs)
8
How May Incarceration Lead to
Elevated Numbers of Sex Partnerships,
Links to High Risk Partnerships?
incarceration
partnership disruption
9
Incarceration: Partnership
Disruption & Risky Partnerships
Incarceration
Risky sexual partnership
• Multiple partnerships
Partnership disruption
10
Incarceration: Partnership
Disruption & Risky Partnerships
Incarceration
Risky sexual partnership
• Multiple partnerships
Partnership disruption
11
Incarceration: Partnership
Disruption & Risky Partnerships
Incarceration
Risky sexual partnership
• Concurrent partnerships
Partnership disruption
12
Incarceration: Partnership
Disruption & Risky Partnerships
Incarceration
Risky sexual partnership
• Transactional sex
Partnership disruption
$$$
$$$
13
Incarceration: Partnership
Disruption & Risky Partnerships
Incarceration
Risky sexual partnership
• Infected partners
Partnership disruption
14
Evidence that Incarceration is
an Independent HIV
Risk Factor
15
Is personal incarceration associated with
HIV risk outcomes including high-risk
sex partnerships and STIs?
16
Personal Incarceration and STI/HIV Risk
Reference
Population
Outcome(s)
PR/OR
Khan et al. 2008
Journal Urban
Health
Venue-based Random
Sample Urban NC
Multiple
Partnerships &
Sex Trade
Khan et al. 2008
Annals of
Epidemiology
Population-based
Random Sample in NC
Multiple Part,
Concurrent Part,
Sex trade
Adjusted PR:
≈2.5
Khan et al. 2009
JAIDS
Network Study Sample,
Bushwick, Brooklyn
Current HIV and
HSV-2 Infection
Adjusted PR:
≈2-2.5
Khan et al. 2011
Journal Urban
Health
US General Population
(NSFG – Men)
Multiple,
Concurrent
Partnerships
Adjusted PR:
≈1.5-2
Epperson et al. 2010 Random Sample of
J Sub Abuse Treat
Women in Methadone
Maintenance, NYC
Multiple
Partnerships,
Sex Trade
Adjusted OR:
2-3
Khan et al. 2011
ISSTDR
Current STI
Juvenile: PR:
2-8.5
US General Pop
(Add Health)
Unadjusted PR:
3-5
17
DOES DURATION MATTER?
Association between
duration of the incarceration and
high-risk sex partnerships?
18
Duration of Incarceration & Risky Partnership among African
American Ages 18–61 years: MEN
(UNC Rural Health Project, North Carolina, 1997–2000, N = 320)
Incarcerated <1 Month
Unadjusted
Adjusted
Prevalence Ratio
Unadjusted Adjusted
Incarcerated 1+ Month
*Potential confounders: Age, age at first sex, education, poverty status, substance use.
SOURCE: Khan et al. 2008 Annals of Epidemiology
19
Weak/Modest Association between Personal Incarceration
and Infection w STI (CT, GC, TP, HSV-2) or HIV
Prevalence ratio
(Networks, Norms and HIV Risk Among Youth Study,
Brooklyn, NY, 2002–2004 N=343)
Incarcerated <1 Year
Incarcerated 1+ Years
Unadjusted Adjusted
Unadjusted
Adjusted
*Covariables: Respondent age, race, unemployment, same sex partnership history,
substance use.
SOURCE: Khan et al. 2011 AJPH
20
To what degree is early and repeated
exposure to incarceration associated
high-risk partnerships?
21
Juvenile v Adult Arrest and STI among Young Adults aged
18–28 Years in the US
(Add Health, 2001-02, N = 14,322)
STI
Juvenile Criminal Justice Involvement
Timing of First Arrest
Never arrested as a juvenile or an adult
Arrested for the first time as a minor
Arrested for the first time as an adult
Persistent Offending
Never arrested as a juvenile or an adult
Arrested as a juvenile, not as an adult
Arrested as an adult, not as a juvenile
Arrested both as a juvenile and an adult
Number of Times Arrested as a Minor
0 times
1 time
2-5 times
6+ times
Unadjusted
OR (95% CI)
Adjusted
OR (95% CI)†
Referent
1.58 (1.09-2.29)
1.10 (0.78-1.55)
Referent
1.53 (1.02-2.29)
1.21 (0.81-1.79)
Referent
1.19 (0.64-2.22)
1.11 (0.78-1.56)
1.98 (1.26-3.10)
Referent
1.35 (0.71-2.56)
1.22 (0.82-1.81)
1.72 (1.06-2.80)
Referent
1.23 (0.73-2.07)
1.30 (0.59-2.84)
7.58 (3.00-19.17)
Referent
1.24 (0.73-2.11)
1.17 (0.49-2.78)
8.58 (2.94-25.1)
†Adjusted for age; gender; race/ethnicity; age at first sex; high school education status of mother/primary caretaker; high school education status of
respondent; poverty level measured at Wave III, defined as difficulty affording housing/utilities in past year; adolescent history of getting drunk or
marijuana, cocaine, or injection drug use; high levels of delinquency in adolescence, defined as a score of 7 on a 7 point delinquency scale; and
indicators of hopelessness in adolescence, including respondent report that he/she would be killed by the age of 21 year and report that he/she would get
22
HIV/AIDS.
Is partner’s incarceration associated
with
high-risk sex partnership?
23
Partner’s Incarceration and STI/HIV Risk
Reference
Population
Outcome(s)
Effect
Estimate
Khan et al. 2008
Journal Urban
Health
Venue-based Random
Sample Urban NC
Multiple
Partnerships &
Sex Trade
Khan et al. 2008
Annals of
Epidemiology
Population-based
Random Sample
Multiple part,
Concurrent part,
Sex trade
Adjusted PR:
≈1.8
Epperson, Khan, El- Random Sample of
Bassel et al. 2011
Women in Methadone
AIDS Behav.
Maintenance
Multiple
Partnerships &
Sex Trade
Adjusted OR:
2-3
Khan et al. 2009
JAIDS
Network Study Sample,
Bushwick, Brooklyn
HIV & Chlaymdia
Adjusted PR:
≈2
Khan et al. 2011
AJPH
Network Study Sample,
Bushwick, Brooklyn
Sex with an
STI/HIV-Infected
Partner
Adjusted PR:
1.9
Current STI
Adjusted PR:
>224
Rogers, Khan, Miller Population-based sample
et al. 2012 STI
in Baltimore, MD
Unadjusted
PR:
6
Is having a sex partner who was
incarcerated a risk factor for exposure to
infected partners?
25
Association between Partner’s Incarceration and Sex with
an STI/HIV-Infected Partner, among those Uninfected with
STI/HIV Infection
Prevalence ratio
Had 1 Partner
in Past 3 Months
Unadjusted Adjusted
Had 2+ Partners in Past
3 Months
Unadjusted
Adjusted
*Covariables: Respondent age, race, unemployment, same sex partnership history,
substance use.
SOURCE: Khan et al. 2011 AJPH
26
What are implications of incarceration
network level HIV risk?
27
NNAHRAY: Sex & IDU Links (Incarceration=Blue Dot; HSV-2=Red Plus)
Do those who live in communities with
high incarceration rates experience
elevated HIV risk?
29
Associations between County-level Incarceration in the Past
Year and Multiple and Concurrent Partnerships in the Past
year among Women Aged 15-44 Years in the US
(2002 National Survey of Family Growth)
County-level
Incarceration Rate
1st Quintile
2nd Quintile
3rd Quintile
4th Quintile
5th Quintile
Multiple
Partnerships*
Referent
1.33 (0.86-3.69)
1.12 (0.72-1.73)
1.49 (0.72-1.92)
1.84 (1.10-3.06)
Concurrent
Partnerships*
Referent
1.02 (0.71-1.48)
0.93 (0.63-1.36)
0.99 (0.65-1.5)
1.49 (0.99-2.25)
*Adjusted for African American race.
(SOURCE: Khan, Adimora, Schonbach (In preparation))
30
Summary of Incarceration
and HIV Risk
• Being incarcerated and having a partner who has been
incarcerated are risk factor for multiple and concurrent
partnerships and links to infected partners
• Associations observed independent of important
confounding factors including drug use
• Those whose criminal justice history began early, and
those with repeat involvement, appear to experience
elevated risk
• Short-term incarcerations may to be important
• Incarceration appears to influence individual, dyadic,
network, and community level HIV risk
31
Evidence of
Incarceration-related
Disruption of Partnerships
32
How commonly does incarceration
disrupt committed partnerships?
What are characteristics of inmates’
partnerships? Are they associated with
lower levels of HIV risk behaviors?
33
NC Priorities for Local AIDS Control
Efforts (PLACE, 2005)
• Survey was given to
assess relationship
status at time of
incarceration, loss of
a partner during
incarceration, current
risk behaviors
• N=373
• Men 229
• Women 144
Geographic Distribution of Venues where People
Meet New Sex Partners in a Central NC City
(2005)
34
Incarceration Disrupts
Partnerships
All men (N=229)
All women (N=144)
31%
Incarcerated ≥1 month
43%
Had committed
partner during longest
sentence of ≥1 month
42%
Relationship
ended during
incarceration
(Khan et al. 2011, STD)
22%
Had committed
partner who was
incarcerated for ≥1 month
32%
Relationship
ended during
incarceration
35
Loss of a Partner During Incarceration was
Associated with HIV Risk Behavior, Among
Those Whose Relationship Was Disrupted By
Incarceration
Loss of Partner Associated with
Multiple New Partnerships:
Adjusted OR: 2.8 (1.1-7.0)
(Khan et al. 2011, STD)
36
NC Priorities for Local AIDS Control Efforts
(PLACE): Prison Pilot Data
• Cross-sectional study.
• Recruited HIV-positive inmates from two prisonbased infectious disease clinics.
• Survey was given to assess relationship status
at time of incarceration, loss of a partner during
incarceration, pre-incarceration risk behaviors.
37
Prevalence and Characteristics of Committed
Relationships among NCDOC inmates
• 52% of NCDOC HIV+ inmates reported
having a primary partner
• Partnerships had characteristics of
“stable” partnerships
•
•
•
•
85% of men in partnerships lived with their partners
>50% shared finances with their partners
>80% saw each other daily or near daily
>60% partners together for 6 months or longer + 30%
together on an off for a number of years
SOURCE: Khan et al. 2011 Journal Urban Health
Why Did Relationships End?
• 55% of partnerships ended during the incarceration
• Of inmates whose relationship ended, the greatest percentages
reported the relationship ended due to….
• The current incarceration (50%)
• Financial concerns (33%)
• Non-monogamy by either partner (33%)
• Problem with drug/alcohol use by either partner (33%)
• Losing a partner during incarceration was NOT associated with
• Respondent socio-demographic factors (race, food insecurity,
education)
• Being incarcerated for drug offense
• Length of incarceration
• Losing a partner during incarceration WAS associated with
current incarceration for a violent offense
SOURCE: Khan et al. 2011 Journal Urban Health
HIV-related Risk Behaviors In 6 Months Prior to Incarceration
Were Lower among Men in Committed Partnerships
• Men who were not in a primary partnership vs men who were….
• 1.3 times more likely to report multiple partnerships
• 1.8 times more likely to report sex trade
• Men who were not in a committed cohabiting partnership vs men
who were….
• 1.7 times more likely to report multiple partnerships
• 2 times more likely to report sex trade
• Men who were not in a committed financially interdependent
partnership vs men who were….
• 1.8 times more likely to report multiple partnerships
• 3-4 times more likely to report sex trade
SOURCE: Khan et al. 2011 Journal Urban Health
Conclusion
• Since committed partnerships may protect
against HIV risk in the community, losing
a partner during incarceration may
contribute to HIV risk during community
re-entry.
Incarceration and HIV Risk:
Public Health Implications and
Future Directions
• Correctional-facility interventions for current prisoners
• Community-based interventions for former prisoners and
partners
• Need longitudinal studies on effects of incarceration on
partnerships and health
42
Current Research: 1R01DA028766-01A1
Longitudinal Study of Relationship Dissolution
During Incarceration and HIV Risk (PI: Khan)
HIV Risk?
Collaborators:
UNC: David Wohl, Carol Golin, Adaora Adimora, Clare Barrington
UMD: Carl Lejuez, Eric Wish, Mei-ling Lee
43
Acknowledgements
Longitudinal Study of Substance Use, Incarceration, and STI
in the US
(NIDA R03 DA026735-01; PI: Khan)
Relationship Disruption during Incarceration and HIV Risk in
African American Men
(NIDA 1R01DA028766-01A1; PI: Khan)
44
Thank you!
• DISRUPT Study Team
• UNC: David Wohl, Carol Golin, Clare Barrington, Selena Monk,
Kathleen Potocnik Medina, Genda Dockery, Shirley Brown
• UMD: Carl Lejuez, Eric Wish, Typhanye Penniman Dyer
• Samuel Friedman, Nabila El-Bassel
• Add Health Study Team
• NDRI: Samuel Friedman, Charles Cleland
• UMD: Amanda Berger, Jordana Hemberg
• NC PLACE Study Team
• UNC: David Wohl, Sharon Weir, Adaora Adimora
• Guilford County, NC: Sherri Harris, Willie Garrison, Caroline Moseley
• NNAHRAY Study Team
• NDRI: Samuel Friedman, Pedro Mateau-Gelabert, Milagros Sandoval
• UNC Prison Working Group
45